1. ________________ D EPARTMENT OF N URSING E DUCATION Nurses Wrestle with the Pros and Cons of Pay-for-Performance Plans Ellen T. Kurtzman, MPH, RN Assistant Research Professor The George Washington University Department of Nursing Education

2. ________________ D EPARTMENT OF N URSING E DUCATION 2 Trends in Hospital Performance Measurement, Public Reporting, Value- Based Purchasing Impact on Nursing Findings from GW Study on Nursing Engagement © The George Washington University Do not cite, quote, or distribute without permission

3. ________________ D EPARTMENT OF N URSING E DUCATION 3 The Quest for Health Care Excellence Quality problems are everywhere, affecting many patients. Between the health care we have and the care we could have lies not just a gap but a chasm. Institute of Medicine, Crossing the Quality Chasm, 2001 © The George Washington University Do not cite, quote, or distribute without permission

4. ________________ D EPARTMENT OF N URSING E DUCATION 4 The Quest for Health Care Excellence I would give great praise to the physician whose mistakes are small for perfect accuracy is seldom to be seen Hippocrates, ca 430 BC

5. ________________ D EPARTMENT OF N URSING E DUCATION 5 The Quest for Health Care Excellence... even admitting to the full extent the great value of the hospital improvements in recent years, a vast deal of the suffering, and some at least of the mortality, in these establishments is avoidable. Florence Nightingale, 1863

6. ________________ D EPARTMENT OF N URSING E DUCATION 6 The Quest for Health Care Excellence If a physician make a large incision with the operating knife and cure it,…, he shall receive ten shekels in money. If a physician make a large incision with the operating knife, and kill him,….his hands shall be cut off. Code of Hammurabi, 1870 BC © The George Washington University Do not cite, quote, or distribute without permission

7. ________________ D EPARTMENT OF N URSING E DUCATION 7 Environmental Context Spotlight on significant gaps in quality health care (e.g., IOM) Escalating health care costs and employer impatience Public awareness and support for improved patient safety Availability of endorsed and standardized performance measures –Set of 15 nursing-sensitive standards (NQF15) –Evidence demonstrates that the size, composition, and other aspects of the nursing workforce affect these processes of care and outcomes Swift federal government policies enabling public reporting, pay-for-reporting, and pay-for-performance © The George Washington University Do not cite, quote, or distribute without permission

8. ________________ D EPARTMENT OF N URSING E DUCATION 8 NQF15 1.Failure to rescue (death among surgical inpatients with treatable serious complications) 2.Pressure ulcer prevalence 3.Falls 4.Falls with injury 5.Restraint (vest and limb) prevalence 6.Urinary catheter-associated UTI - ICU 7.Central line catheter-associated BSIs - ICU 8.Ventilator-associated pneumonia - ICU © The George Washington University Do not cite, quote, or distribute without permission

9. ________________ D EPARTMENT OF N URSING E DUCATION 9 NQF15 9.Smoking cessation counseling for AMI 10.Smoking cessation counseling for pneumonia 11.Smoking cessation counseling for HF 12.Skill mix 13.Nursing care hours per patient day 14.Practice Environment Scale-Nursing Work Index (PES- NWI) 15.Voluntary turnover © The George Washington University Do not cite, quote, or distribute without permission

10. ________________ D EPARTMENT OF N URSING E DUCATION 10 Hospital Performance Measurement and Reporting NQF-endorsed TM national voluntary consensus standards for nursing-sensitive care (NQF; 2004) Proliferation of alliances devoted to transparency and accountability (e.g., Hospital Quality Alliance) Emergence of state reporting efforts focused on nursing performance (Maine, Massachusetts) Hospital Compare launched in 2005 –More than 4,000 hospitals currently participate –30 measures presented for comparison (26 process, 3 outcome, HCAHPS) + payment/volume data –HCAHPS – survey of hospital experience including nurse communication & other nursing-related items © The George Washington University Do not cite, quote, or distribute without permission

11. ________________ D EPARTMENT OF N URSING E DUCATION 11 VBP: Pay for Reporting Rapid expansion of Hospital Compare under the MMA which paved the way for pay for reporting Pay for reporting = Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) initiative FY2009 IPPS final rule (CMS-1390-F, August 2008) expands RHQDAPU from 30 to 42 measures –Retires 1 pneumonia oxygenation assessment measure – hospitals not required to submit data beginning January 1, 2009 –Increases number of measures that are required for the full APU in FY2010 by 13 –One nursing-sensitive measures are among the required measures (i.e., failure to rescue) –Intent to adopt 2 additional measures (AMI and PN readmission rates) in the CY2009 OPPS/ASC © The George Washington University. Do not cite, quote, or distribute without permission.

12. ________________ D EPARTMENT OF N URSING E DUCATION 12 VBP: Pay for Performance Pay for reporting = Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) initiative RHQDAPU to transition to P4P in 2009??? Report to Congress on transition from RHQDAPU to P4P (available at: http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/Ho spitalVBPPlanRTCFINALSUBMITTED2007.pdf) http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/Ho spitalVBPPlanRTCFINALSUBMITTED2007.pdf Link payment to performance Hospital-acquired conditions (HACs, never events) provision under FY2008 IPPS rule (CMS-1533-FC) first hospital P4P initiative © The George Washington University Do not cite, quote, or distribute without permission

13. ________________ D EPARTMENT OF N URSING E DUCATION 13 Hospital-acquired Conditions Value-based purchasing reform under IPPS (CMS-1553-FC) Beginning with October 1, 2008 discharges, reimbursement will be eliminated for selected inpatient conditions/complications: Occur during the hospitalization Are preventable Are secondary diagnoses Bump up higher reimbursement CMS-1390-F required inclusion of 3 additional hospital-acquired conditions (manifestations of poor glycemic control, surgical site infections, and deep vein thrombosis/pulmonary embolism) (1)pressure ulcers* (2)certain preventable inpatient injuries* (i.e., fractures, dislocations, intracranial injuries, crushing injuries, burns) (3)catheter-associated urinary tract infections (UTIs)* (4)vascular catheter-associated infections (BSIs)* (5)certain surgical site infections (SSIs) (6) objects left in surgery (7) air embolism (8) blood incompatibility * = NQF-endorsed TM national voluntary consensus standard for nursing-sensitive care © The George Washington University. Do not cite, quote, or distribute without permission.

14. ________________ D EPARTMENT OF N URSING E DUCATION 14 Hospital-acquired Conditions Pressure ulcers (257,412 cases of stage III and IV ulcers, $43,180/hosp) Preventable injuries such as fractures, dislocations, and burns (193,566 cases, $33,894/hosp) Catheter-associated urinary tract infections (12,185 cases, $44,043/hosp) Vascular catheter–associated infections (29,536 cases, $103,027/hosp) Certain surgical site infections (69 cases, $299,237/hosp) Objects mistakenly left inside surgical patients (750 cases, $63,631/hosp) Air emboli (57 cases, $71,636/hosp) Blood incompatibility reactions (24 cases, $50,455/hosp) © The George Washington University. Do not cite, quote, or distribute without permission.

15. ________________ D EPARTMENT OF N URSING E DUCATION 15 Hospital-acquired Conditions Manifestations of poor glycemic control –Diabetic ketoacidosis (11,469 cases, $42,974/hosp) –Nonketotic hyperosmolar coma (3,248 cases, $35,215/hosp) –Hypoglycemic coma (212 cases, $36,581/hosp) –Secondary diabetes with ketoacidosis and with hyperosmolarity (data not available) Surgical site infections –Certain orthopedic surgeries (269 cases, $148,172/hosp) –Bariatric surgery for obesity (37 cases, $233,614/hosp) Deep vein thrombosis/pulmonary embolism following certain hip and knee replacement surgeries (4,250 cases, $58,625/hosp) © The George Washington University. Do not cite, quote, or distribute without permission.

16. Nursing 911 Nurses as the first responders…………. © The George Washington University Do not cite, quote, or distribute without permission 21

17. ________________ D EPARTMENT OF N URSING E DUCATION 17 VBP: Implications for Nursing Growing body of evidence that links nursing care to patient outcomes Among specific subpopulations, evidence points to a nurse staffing- outcome effect for failure-to-rescue rates, inpatient mortality, and length of stay; effects are especially pronounced in surgical inpatients Nurses are drivers in coordinating, delivering, and documenting care related to RHQDAPU measures (e.g., vaccination, discharge instructions for HF) Higher registered nurse staffing patterns have been associated with higher quality care on AMI, HF, PNEU composite measures (Landon et al., Arch Intern Med. 2006) Half of the hospital-acquired conditions have been linked by the evidence to nursing and endorsed by NQF as voluntary consensus standards (i.e., pressure ulcers, falls with injury, catheter-associated urinary tract infections, vascular catheter-associated infections) © The George Washington University. Do not cite, quote, or distribute without permission.

18. ________________ D EPARTMENT OF N URSING E DUCATION 18 Hospital-acquired Conditions Implications for Nursing Elimination of reimbursement will emphasize nursings role in the prevention of these complications triggering an investment in nursing? Studies demonstrate reductions in these complications are achievable stimulating quality improvement? Reactions to negative sanctions will span continuum Bright increased recognition in the value of investing in nursing strengthening of nursing systems performance Systems approach maintained Bleak fiscal restraint and workforce modifications that weaken nursing Blame game Protectionism and avoidance of helping behaviors © The George Washington University. Do not cite, quote, or distribute without permission.

19. Where is Nursing? Engaging the Single Largest Health Care Workforce © The George Washington University. Do not cite, quote, or distribute without permission

20. ________________ D EPARTMENT OF N URSING E DUCATION 20 Nursing Engagement in Performance Measurement and Public Reporting RWJF-funded, 24-month project Responds to current policy directions that relate to transparency and accountability Primary aims: –Analyze current policy directions that impact nurses –Identify key issues, challenges, and opportunities through qualitative data gathered from interviews with hospital executives, nurses, hospital trustees, and national organizations of import –Activate and strategically engage nursing community –Commit to and accelerate the availability of publicly reported nursing performance data –Encourage and advocate for policies that recognize nurses contributions to quality and safety National Advisory Committee co-chaired by Drs. Dennis OLeary and Mary Wakefield Collaboration with AAN, ANA, AONE, others…. © The George Washington University. Do not cite, quote, or distribute without permission

21. ________________ D EPARTMENT OF N URSING E DUCATION 21 Nursing Engagement: Progress to Date Phase 1: Inventory and analyze current landscape (2007-08) Inventory of current state of nursing performance measurement, public reporting of these data, and value-based purchasing Business case for incentivizing high quality nursing care Phase 2: Translate findings into actionable strategies (2008-09) Conceptual framework for nursing performance measurement, public reporting of these data, and value-based purchasing Position papers, guiding principles, and near and long-term strategies to facilitate greater penetration of incentive programs and advance policymaking that recognizes the contribution of nursing Semi-structured interviews with hospital executives, nurses, trustees, and representatives of national organizations to solicit perspectives on national policy directions © The George Washington University. Do not cite, quote, or distribute without permission

22. ________________ D EPARTMENT OF N URSING E DUCATION 22 Nursing Engagement: Soliciting Perspectives on Policy Directions Over 100 semi-structured interviews conducted by telephone (n=33) and in-person (n=69) during site visits to 7 hospitals/health systems Solicited perspectives of hospital executives (e.g. c-suite), nurses, trustees, and representatives of national organizations of import (e.g., government agencies, accreditation organizations, professional nursing organizations, labor groups) Content focused on perspectives related to nursing performance measurement, public reporting of these data, financial incentives to stimulate improvements in nursing quality, and responses to federal policies (e.g., CMS hospital-acquired conditions policy) Descriptive analyses of demographic data and qualitative techniques derived from a modified content analysis will be used to interpret the interview data and synthesize themes © The George Washington University. Do not cite, quote, or distribute without permission

23. ________________ D EPARTMENT OF N URSING E DUCATION 23 Strengthening Nursings Voice in Policy © The George Washington University Do not cite, quote, or distribute without permission

24. ________________ D EPARTMENT OF N URSING E DUCATION 24 Planning a Nursing Quality & Safety Alliance Natural extension of GW portfolio 12-month RWJF-funded planning grant Explores the nature of nursings voice in transparency and accountability policies and the need for a unified policy voice GW as neutral convener to facilitate discussions with leaders from representatives from national nursing organizations Responds to key questions: How might nursing strengthen its voice in policy related to performance measurement, public reporting, and value-based purchasing? What formal arrangements, if any, should be pursued – vis-à-vis establishing a nursing quality and safety alliance – to ensure that nursings voice is unified on these issues? © The George Washington University Do not cite, quote, or distribute without permission

25. ________________ D EPARTMENT OF N URSING E DUCATION 25 Questions? © The George Washington University Do not cite, quote, or distribute without permission

26. ________________ D EPARTMENT OF N URSING E DUCATION Ellen T. Kurtzman, MPH, RN Assistant Research Professor George Washington University Department of Nursing Education 900 23 rd Street, NW Room 6185 Washington, DC 20037 E: hspetk@gwumc.eduhspetk@gwumc.edu T: 202.994.9439 Web: http://www.gwumc.edu/healthsci/ For more information: © The George Washington University Do not cite, quote, or distribute without permission